934 Septic Pumping Report 2010 Important:
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Commonweal oflvlassachusetts
City/Town of/V?
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 OMR 15.351.
A. Facility Information
System Location:
Address
City/Town
2. System Owner:
• u su ;n ; 9 � {
Na
q7c( $pLn Q,iy
Address(if different from Iota ion)
t5farm4 dac•03/06
Zip Code
City/Town
State/3 i).—TV
Telephone Number
B. Pumping Record
Na' IS/a 1540
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) _I aeptic Tank ] Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? fl Yes 'INo If yes, was it cleaned Yes ❑ No
5. 6Co//n,ditio of System.
6. S sy teµ�yf�umped By.
Name, /,`
Company
Location yvhere cggtents were disposed:
p�1 ,S (Jt
Vehicle License Number
Signature of Hauler
Date
Signature of Receiving Facility
Date
System Pumping Record•Page 1 of 1